Agenda item

Purpose of report:Scrutiny of Services

Following the high level of demand on NHS A&E units across the country and the effect on performance the Committee has requested that Ashford & St. Peter’s Hospitals Foundation Trust and its partners provide an analysis of the pressures in their area including detail on the immediate response to the increased demand and how the system is planning to cope going forward. The Trust has been approached as it has demonstrated resilience in this period and can provide evidence of the lessons learnt as it steps down from major incident status.

Declarations of interest:

None

Witnesses:

Suzanne Rankin, Chief Executive, Ashford and St Peter’s Hospitals Foundation Trust

Julia Ross, Chief Executive, North West Surrey Clinical Commissioning Group

Shelley Head, Area Director (North West Surrey), Adult Social Care

Sarah Wardle, Head of Community Care and Rehabilitation, Virgin Care

Nick Markwick, Director, Surrey Coalition of Disabled People

Key points raised during the discussion:

The Chief Executive of North West Surrey CCG (CENWS), who also is the head of the area’s system resilience group, highlighted that she was proud of the way in which all partners across the system had coped with the unprecedented level of demand that occurred over winter. Attention was drawn to statements made by the Care Quality Commission (CQC) which congratulated Ashford and St Peter’s Hospital Foundation Trust and its staff on their response to this demand. Confirmation was given, however, that procedures are currently being developed across the system in North West Surrey to improve resilience and responses to an unforeseeable escalation in demand on A&E services.

·         The Committee asked for clarification on what a major incident is in practice and the reasons why it was declared at St Peter’s hospital. CENWS advised that declaring an internal major incident mobilises partners across the system such as the Ambulance Service and the Council as well as providing access to a range of measures and resources to help manage the sharp increase in demand experienced by the hospital. The Chief Executive of Ashford and St Peter’s Hospitals Foundation Trust (CESAP) highlighted that the sheer volume of patients attending A&E at St Peter’s hospital jeopardised patient safety as it was operating at its maximum capacity. The decision to declare a major incident was necessary so that enough staff, beds and other resources were available to ensure all patients continued to receive a high standard of care despite the pressures on the hospital.

·         The Committee were further informed that declaring a major incident also establishes a control room from which directors can manage the hospital centrally and ensure all patients that attend A&E receive the required care. The CESAP did acknowledge that the declaration would garner media scrutiny and political interest but it was decided that declaring a major incident was the right thing for the Trust to do at the time and that it was correct for this status to be maintained until pressures on the hospital had reduced to the extent that it was felt that the hospital was able to function normally.

• Information was requested on the number of people that were anticipated to pass through A&E through winter 2015/16 and the plans in place to meet the forecasted demand. The CENWS stated that demand throughout the year is, in the main, relatively predictable but that it is impossible to plan for spikes in demand that cannot be anticipated. The Committee were advised, however, that plans are being developed to improve the resilience of the system when these increases in demand occur through initiatives including GP-led locality hubs, strategies to increase the provision of domiciliary care as well as creating the ‘beyond black’ system wide indicator which allows the Trust to access additional resources when required without the need to declare a major incident.

• The CEASP followed up by stating that much of the pressure stemmed from the number of patients that attended A&E with numerous co-morbidities and that this was particularly pronounced among those aged over 75. Multiple speciality assistance was also in high demand due to a 28% jump in the number of patients with cognitive impairments such as dementia who often require additional time and resources. No-one predicted this level of demand in this cohort of patients but it is agreed that a change is required in how the NHS provides care for the elderly to ensure it is routine and predictable.

• Members were advised that increased pressure on acute hospitals was a national problem and that the reasons for this are not yet fully understood although work is ongoing with Public Health to shed more light on the factors behind this demand spike. The CEASP indicated that it would be unsustainable to put the resources and facilities in place to cater for this level of demand at all times as it would be unaffordable and inefficient once the demand had subsided. Instead, Members were advised that levels of escalation are required to ensure that the resources and facilities can be accessed when required.

• The Director of Surrey Coalition of Disabled People (DSCDP) expressed concern with discharge arrangements at St Peter’s hospital and asked whether increased pressure on the hospital over winter had meant that some patients had been sent home from hospital before they were ready. The CENWS advised that some pressure on acute hospitals was a result of the fact that the opposite was true and that in many cases patients are kept in hospital longer than required. The role of acute hospitals in the care system was also highlighted to the Committee and it was indicated that there are better environments for patients to convalesce or be rehabilitated and that a frank public discussion is required regarding what acute hospitals are for and their function within the wider healthcare system.

• Members asked whether the 95% target set by the government for seeing patients within four hours is useful or realistic assessment for the performance of A&E departments and whether efforts to meet this target impacted on the quality of care the hospital was able to deliver. The CEASP advised the Committee that there isn’t disagreement with the target based on the evidence, however, in times of pressure - for example in ‘beyond black’ scenarios - the targets are less important and they can be selective about how they manage meeting it for the sake of patient safety and quality of care.

• The Committee expressed concern that much of the demand placed on acute hospitals over the winter resulted from the deterioration in individuals with existing, known health conditions. Details were requested on what action is being taken to create a model of care in the community that prevents this.Locality hubs were highlighted as a significant step towards making joined up services available in the community that will be able to effectively care for patients with existing health conditions and prevent escalation. Strategies designed to strengthen links between acute hospitals and community care services will also be implemented and include making community matrons and pharmacy services available within care homes. The Head of Community Care and Rehabilitation at Virgin Care (HCCR) stressed that there is a need to match the skills of nurses and community carers to patients. The HCCR confirmed that Virgin Care is working with North West Surrey CCG to provide predictable, routine care that prevents escalation, particularly among elderly patients. The Area Director also informed the Committee that the Adult Social Care is working closely with providers to develop a joined up approach to delivering care, particularly for elderly patients.

·         Members drew attention to the consistency of care across the Trust citing examples of both excellent and poor care experienced by patients. The CEASP confirmed that efforts are being made to support all 5,000 staff across the Trust to deliver the best care possible to all patients. Improvements in the Trust’s performance against quality indicators suggest that these measures are working and that the consistency of care across both hospitals is getting better. The CEASP reminded the Committee that the Trust is on an improvement journey as has moved from the bottom of the ranks to the middle and, in some cases, to leading the country in some quality indicators such as weekend mortality.

Recommendations:

1.   The Committee recognises the system’s response in North West Surrey including the actions of the Clinical Commissioning Group, Ashford & St. Peter’s Hospitals, Virgin Care and the council’s Adult Social Care teams to protect lives during a period of substantially increased demand centred on the acute hospital.

Actions/further information to be provided:

1.   The Committee recommends that it receives a further update in September from the partners in this system on the steps taken in the wake of 2014/15 to minimise the need to declare 'Major Incident' status and reinforce resilience in the north west of Surrey.

Committee next steps:

1.   The Committee recommends that it contact the health and social care leaders in the rest of the county to highlight any potential risks for the 2015/16.